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Human factors and medication errors: a case study

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 Art & science
section, email gwen.clarke@rcnpublishing.co.uk or
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Human factors and medication
errors: a case study
Gluyas H, Morrison P (2014) Human factors and medication errors: a case study.
Nursing Standard. 29, 15, 37-42. Date of submission: August 22 2014; date of acceptance: September 30 2014.
Abstract
Human beings are error prone. A significant component of human error
is flaws inherent in human cognitive processes, which are exacerbated
by situations in which the individual making the error is distracted,
stressed or overloaded, or does not have sufficient knowledge to
undertake an action correctly. The scientific discipline of human factors
deals with environmental, organisational and job factors, as well as
human and individual characteristics, which influence behaviour at
work in a way that potentially gives rise to human error. This article
discusses how cognitive processing is related to medication errors.
The case of a coronial inquest into the death of a nursing home resident
is used to highlight the way people think and process information,
and how such thinking and processing may lead to medication errors.
Authors
Heather Gluyas, post-graduate lecturer in patient safety, quality and
clinical governance, School of Health Professions, Murdoch University,
Perth, Australia.
Paul Morrison, dean, School of Health Professions, Murdoch
University, Perth, Australia.
Correspondence to: h.gluyas@murdoch.edu.au
Keywords
Case study, drug calculations, education, errors, human factors,
medication, medication errors, patient safety
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If you would like to contribute to the Art & science
@NSclinicalEd
HUMAN BEINGS ARE prone to making
mistakes. Human fallibility is exacerbated
in situations where the person involved is
stressed, distracted, tired, interrupted frequently
or overloaded with tasks (Endsley 2012).
The scientific discipline of human factors,
sometimes referred to as human factors and
ergonomics, seeks to understand what makes
people error prone, and then to design systems,
processes, work environments and technology
that lessen the likelihood of human error (Russ
et al 2013). Human factors as a concept has been
defined by the Health and Safety Executive (2009)
as: ‘environmental, organisational and job factors,
and human and individual characteristics, which
influence behaviour at work in a way which can
affect health and safety’.
This article discusses how thought or cognitive
processing is related to different types of error.
The case of a coronial inquest into the death of
a nursing home resident and a medication error
that preceded the death is used to highlight the
way people think and process information,
and how such thinking and processing may
lead to a medication error. Strategies developed
from the study of human factors, which could be
implemented to lessen the likelihood of similar
incidents, are also presented.
Cognitive function and errors
Humans have unique cognitive capabilities that
enable multitasking, problem solving and the
prioritisation of urgent requirements. They are
able to undertake certain tasks without conscious
effort, for example driving a car (an extremely
complex task) while talking to a passenger, at the
same time as navigating in heavy traffic to a
december 10 :: vol 29 no 15 :: 2014 37
03-12-2014 19:01:47
 Art & science patient safety
new destination (Gluyas and Morrison 2013).
However, these cognitive skills come with the
drawback that humans have limited cognitive
processing capabilities, and are prone to slips,
lapses and mistakes, especially in circumstances
where individuals are stressed, have a heavy
workload or are undertaking unfamiliar tasks
(Reynard et al 2009).
Rasmussen and Jensen (1974) proposed that the
way humans function at a cognitive level changes
according to the actions being undertaken.
They proposed three different types of cognitive
performance based on the degree to which actions
or problem solving are directed by the conscious
or automatic functions of the mind. The three
types of performances are (Parker and Lawton
2006, Dekker 2011, Carayon 2012, Endsley
and Jones 2012):
Skill-based, which is automatic, requires limited
attention, is fast and effortless.
Rule-based, which requires a combination of
automatic and conscious attention, relying
on training or experience to make choices
about actions.
Knowledge-based, which relies on conscious
attention directed to new or novel situations,
and requires cognitive effort.
Skill-based performance is liable to slip-and-lapse
types of error, for example forgetting to do
something, doing something incorrectly or leaving
a step out of a process. Such errors are more likely
to happen when the individual is interrupted or
distracted by competing priorities (Reason 2004).
Slips and lapses may also be related to the
misidentification of objects (Reason 2008).
Humans have limited cognitive resources in terms
of the amount of information that can be processed
at any one time. When undertaking routine tasks
automatically, humans unconsciously filter the
information that the brain receives at the conscious
level and fill in the gaps in the cognitive processing
of the mental picture that is formed to guide the
action being undertaken (Endsley and Jones 2012).
What can happen during such automatic routine
activity, therefore, is that humans see what they
expect to see (Endsley and Jones 2012). Applying
the above to the occurrence of medication errors,
it is easy for practitioners simply to see the wrong
medication label, for example where similar
packaging or a similar dose is involved (Institute
for Safe Medication Practices 2009).
Rule-based actions may give rise to mistakes,
since they require retrieval of a mental model,
also known as a schema (stored knowledge of
what an object, scenario or event is, and/or what
it means), that fits the requirements for the current
situation (Endsley and Jones 2012). The retrieval
38 december 10 :: vol 29 no 15 :: 2014
NS_0117.indd 38
process relies on pattern matching (‘this is the same
as that’) or frequency gambling (unconsciously
choosing the most frequent schema in similar
circumstances). Rule-based mistakes happen when
a situation has been assessed incorrectly or the
wrong schema is retrieved (Dekker 2011).
Mistakes may also occur during
knowledge-based actions if the action is based
on inadequate knowledge to allow successful
completion of the task (Woods et al 2010).
When faced with an unfamiliar task, as with
rule-based actions, the memory is searched for
schemata that will provide information to enable
the task to be undertaken correctly. Lack of
previous experience in undertaking the task, or a
similar task, means the individual does not have
a store of appropriate schemata from which to
choose, potentially resulting in the task being
undertaken incorrectly (Dekker 2006).
Slips, lapses and mistakes are all more likely
to happen if a person is stressed or distracted
by a demanding workload or busy environment
(Gluyas and Morrison 2013). This complex
interaction between cognitive processing and
organisational or system factors leading to errors
has been described by Reason (2004) as active
failure influenced by latent factors. The actual
error at the point of care is termed the active
failure, and the many contributory organisational
or system factors are the latent factors. Before
discussing these factors in relation to medication
errors, an Australian coroner’s report, conducted
following the death of a nursing home resident,
will be used to highlight the causes of a medication
error that occurred before the resident’s death.
The inquest
In March 2013, a coronial inquest was held
into the death of a nursing home resident in
Australia. The coroner found that the cause of
death was related to underlying disease and that
no person contributed to his death. However,
in the course of the inquest it was established that
a medication error had occurred in the hours
preceding the resident’s death, involving the
subcutaneous administration of 25mg of morphine
instead of 2.5mg.
The coronial report identified that the nurse
involved was a new graduate, working her second
shift as a registered nurse at the nursing home.
The nurse had not undergone the requisite two
days’ orientation or ‘buddying’ required for new
members of staff at the nursing home. During
the shift in question, the nurse was in charge,
working with three extended care assistants
(nursing assistants). There were 36 residents,
© NURSING STANDARD / RCN PUBLISHING
03-12-2014 19:01:47
 of whom 18 were classified as ‘high care’ and nine
as ‘medium care’. The care of one resident
required a significant amount of attention from
the nurse, which involved ongoing interaction
with other healthcare professionals, external to
the organisation. This resulted in time pressures
with regard to meeting the nursing care needs of
the other residents. While the nurse was occupied
liaising with external healthcare professionals,
the extended care assistants reminded the nurse
several times that the resident, who subsequently
became the subject of the coronial inquest,
required morphine, which was overdue. All of
the above constitutes the latent factors that may
have affected, to varying degrees, the active
failure that occurred when the nurse administered
the wrong morphine dose to the resident.
In error, the nurse administered 25mg instead
of 2.5mg and discovered the mistake when she
went to prepare the next dose of morphine.
The nurse described in her affidavit the process of
preparing the morphine:
‘I went to the drug storage room at the facility
and removed a package of morphine… I quickly
looked at the packaging and incorrectly saw
1mg/1mL, whereas the correct ampoule strength
was 10mg/1mL. The medication order was
for 2.5-5mg morphine sub/cut per four hours.
I drew up 25mg/2.5mL, as the correct packaging
was for 10mg/1mL. I had never administered
morphine before and, as previously mentioned,
had not viewed the packaging and labelling of
morphine ampoules. I was not familiar with the
standard dosage of morphine. I asked one of the
carers… who was with me at the time to check the
dosage with me… (the extended care assistant)
double-checked the dosage but did not notice my
mistake either…’ (Magistrates Court of Tasmania
Coronial Division 2013).
Medication errors
Errors are common in health care. Studies
identify that one in ten patients will experience
an adverse event as the result of an error. One in
five of these will experience severe injury and
one in 30 will die (Wilson et al 1995, Wilson
and Van Der Weyden 2005, World Health
Organization (WHO) 2005. Medication errors
are a significant contributor to adverse events,
being the second most frequently reported error
(Wachter 2012). By reviewing the case presented
above it is possible to identify the active error
as the administration of the incorrect dose of
morphine. The cognitive factors that may have
influenced the active error relate to all three types
of cognitive performance (Table 1).
© NURSING STANDARD / RCN PUBLISHING
NS_0117.indd 39
The skill-based error relates to unconscious
automatic processing with regard to seeing
what was expected when reading the dosage
on the medication label. It is likely that, having
read the required dose on the medication chart,
2.5-5mg, the nurse was expecting to see a dosage
on the medication packaging that would require
administration of 2.5-5mL of the drug. This is
supported by the wording used in the statement
quoted above: ‘… I drew up 25mg/2.5mL…’.
The checking process by the extended care
assistant was most likely to have been an automatic
rather than mindful process, so the error was not
detected. In Australia, extended care assistants
may double check medication if the policies and
procedures of the organisation permit.
The rule-based component of the error related
to the retrieval of an incorrect schema regarding
the different types of syringes and needles that
are used for different routes of administration.
Previous experience, as a student during the
education process or clinical placement, would
have covered the process of drawing up medication
for an injection, but may not necessarily have
differentiated the different sizes of syringes and
needles that are available, and which should be
used for a subcutaneous injection. Thus, the nurse
applied the schema with regard to the size of the
syringe to the volume of fluid (2.5mL) she was
expecting to administer.
Finally, the knowledge-based component of
the error involved the lack of previous experience,
which meant there was inadequate knowledge of
the usual dosage and volume that is administered
by the subcutaneous route. The relatively high
volume to be injected subcutaneously, or the
need to use three vials to obtain the dose, might
have alerted an experienced nurse. However,
such experience was not available to the
nurse in this case.
As noted previously, cognitive performance
can be undermined by factors such as stress,
workload, distractions and undertaking
TABLE 1
Cognitive performance factors related to the medication error
Cognitive performance Example
Skill-based Reading 1mg/1mL instead of 10mg/1mL.
Automatic checking by second person did not
detect error.
Rule-based Wrong schema used in terms of size of syringe
and needle.
Knowledge-based No previous experience of morphine
administration. Unfamiliarity with standard
dosage and volume administered by the
subcutaneous route.
december 10 :: vol 29 no 15 :: 2014 39
03-12-2014 19:01:47
 Art & science patient safety
unfamiliar tasks. In reviewing this case it is
possible to see significant stress factors related
to the nurse performing her new role, including
having to liaise with external healthcare
professionals while managing residents’ nursing
care. In addition, she was inexperienced with
regard to the responsibility of managing other
workers, and she had received insufficient support
or orientation. The nurse was also interrupted
frequently by being reminded that medication was
overdue. The workload was high: there were 36
residents, half of whom were classified as having
‘high needs’, all required medication and several
required ongoing nursing interventions. Finally,
the nurse was required to undertake a medication
round and administer medication with which she
was unfamiliar. Other latent factors that affected
this situation include a lack of professional, on-site
support and a lack of adherence to policies such as
orientation for new staff members.
Human factors strategies
Human factors strategies targeting the reduction
of errors involve designing systems, processes,
work environments and technology that recognise
human fallibility (Carayon 2012). There are
several human factors strategies that may decrease
the likelihood of medication errors of the type
described in the case above. Avoiding reliance on
memory is a human factors strategy that requires
protocols and evidence-based resources to be
readily available against which practitioners may
check their knowledge (Beaumont and Russell
2012). These resources might be in the form of
written or software resources. However, the key
to error reduction is that the resources are easily
accessible and that a culture exists that encourages
the use of such resources. It was not possible to
establish if such resources were available in the
case described.
Another strategy based on human factors
involves making things highly visible. This would
include posters or diagrams that detail the
steps and the considerations necessary when
undertaking a certain task (Mahlmeister 2009).
In this situation a poster describing the dosages
contained in morphine ampoules and a calculation
table of dosage versus volume might have alerted
the inexperienced nurse to the overdose.
The use of checklists, briefings and verbal
double-checking protocols can lessen the
likelihood of error in medication administration
(Fryer 2012). However, checking procedures
are shown to be useful only if undertaken with
conscious attention. If undertaken in a routine,
automatic way, then they are prone to the slips
40 december 10 :: vol 29 no 15 :: 2014
NS_0117.indd 40
and lapses that accompany automatic processes
(Wachter 2012). Organisations that have a culture
in which checks are undertaken mindfully find
this to be an effective strategy in error prevention.
However, the culture in health care is that these
checks are often cursory (Shearer et al 2012,
Wachter 2012).
Increasing individuals’ awareness of human
fallibility can highlight situations where the
potential for error is increased. Mnemonics such
as IMSAFE (illness, medication, stress, alcohol,
fatigue and emotion) challenge the individual to
assess frequently which factors are present that
might increase the potential for error (WHO
2011). The three-bucket model (Reason 2004)
is similar; it asks the person to assess their current
situation against factors of increased stress
focusing on self, context and task, represented
by the buckets. The more negative factors that
are in each of the buckets, the higher the risk of
error. In this case study the nurse would have had
significant risks in each of the buckets, which may
have been enough to highlight the significant risk
of error had the nurse or the organisation been
aware of this model (Boakes 2009).
Increasing organisational awareness of
error probability and human fallibility related
to cognitive processing and overload, should
encourage attention to workload and resourcing
issues, supervision and professional support
strategies, thereby mitigating the chance of
medication error (Reid-Searl et al 2010). A positive
organisational safety culture is also an important
feature in the prevention of errors, including
those involving medication (Morello et al 2013).
This type of culture supports the monitoring of
errors and risk mitigation, and empowers staff
members to notify the organisation about concerns
and safety risks.
The nurse in the case study was a new
graduate with limited experience. The use of
scenario-based simulations is a strategy that
can be employed in educational and clinical
sectors. Simulation provides the opportunity to
address knowledge-based and rule-based errors
(Habraken and van der Schaff 2008). In terms of
recognising and responding to the deteriorating
patient, simulated experiences provide a pool of
cognitive schemata on which decisions for action
may be based. They also provide the opportunity
to develop these schemata in a non-threatening
environment (Pian-Smith et al 2009). Although
it is impossible to prepare graduate nurses
to be familiar with all situations, the use of
simulation, particularly in relation to error-prone
situations such as medication administration, is a
valuable technique.
© NURSING STANDARD / RCN PUBLISHING
03-12-2014 19:01:47
 There are other general human factors strategies
that do not apply in this particular case but may be
applicable in similar cases. These include the use
of forcing functions. Forcing functions decrease
the likelihood of error by forcing conscious
attention to an automatic task. An example of
this is a syringe infusion pump for administration
of subcutaneous medication that will take only a
certain size of syringe or quantity of medication.
Trying to force the wrong syringe or medication
amount into the infusion pump forces the person
to think about why the process will not work
(Sawyer 2014).
Storage and packaging of medication to ensure
that look-alike or sound-alike dosages of the
same drug are not stored together, or available
in similar-looking packages, has been shown
to reduce the incidence of medication errors
(Filik et al 2006). Standardisation of terms and
abbreviations in line with recommendations for
good practice from medication authorities is
important in decreasing the likelihood of slips,
lapses and mistakes (Australian Commission on
Safety and Quality in Health Care 2013). Finally,
recognising that distractions and interruptions
increase medication errors, many organisations
have instituted no-interruption zones or the
wearing of no-interruption vests when staff
are involved in medication administration,
although the evidence for this type of intervention
still requires robust studies to validate its
effectiveness in reducing medication incidents
(Australian Commission on Safety and Quality in
Health Care 2013).
Conclusion
The coroner’s inquest findings related to the
case described cleared the nurse who made the
medication error of involvement in the subsequent
death of the resident. However, a medication error
occurred during the care of that resident. Humans
are unique in their ability to solve problems,
multitask, and manage complicated tasks and
complex situations. The way humans function
cognitively and process information permits this
to happen, often without conscious attention.
However, these same processes also make humans
error prone. Recognising this in terms of health
care is vital as it provides the opportunity to
increase patient safety by focusing on strategies
that decrease cognitive load and decrease the
likelihood of error. The discipline of human
factors seeks to understand what makes people
error prone, and to design systems, processes,
work environments and technology that lessen
the likelihood of human error NS

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